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New challenges and quality improvement in outpatient cardiology care in Spain

An article from the e-journal of the ESC Council for Cardiology Practice

In Spain, long waiting lists due to the aging of the population coupled with a high prevalence of cardiovascular diseases and an increased use of non-invasive complementary tests have led to the saturation of the national health-care system. Simplifying cardiology assistance by performing the greatest number of necessary tests on the same day of the patient's visit thanks to the “Continuous Quality Improvement model”, as well as ensuring the availability of echocardiograms in the office will help to improve out-patient care.

1) Background

In recent years, new problems have emerged in the Spanish public healthcare system, one of the greatest of which is the long waiting lists to be assisted by a cardiology specialist and for the various complementary tests (echocardiogram, exercise ECG testing, ambulatory monitoring, stress myocardial perfusion imaging, among others) to be performed. These delays equally affect those patients referred by primary care clinicians and those referred by other specialists seeking check-ups.
Many patients today demand to be seen by a cardiologist, and the aging of the population with a high prevalence of cardiovascular diseases has led to the saturation of the system. Another change is the increased use of non-invasive complementary tests. The popularity of these tests and the fact that their results are well-established have increased the demand for them, with the pressure to perform these tests also coming from the patients themselves. Another factor is that certain doctors prefer to confirm their hypotheses regarding the presence or absence of a disease by means of an objective test.
The waiting time necessary to be seen by a cardiologist, added to the time invested in the different complementary tests, and the final visit to discuss results directly affects the efficiency and the quality of medical assistance. For the individual patient, the final results have the same importance whether the murmur is benign or due to severe aortic stenosis. In both cases, the months spent waiting should not be considered innocuous for mental or physical health.
Over the last 40 years, while the speciality of cardiology has developed multiple diagnostic and therapeutic advances, the organisation of specialised out-patient care in the Spanish public healthcare system has not shown any major advances. Despite their great personal efforts, most cardiologists have presented low efficacy. Physicians working in ineffective offices run the risk of work dissatisfaction.

Moreover, there is a lack of scientific evidence and recommendations concerning the work organisation with cardiology out-patients. There are no guidelines detailing how check-ups must be done. Guidelines focus on patient conditions rather than on procedures, and efforts must be made in implementation and overall quality improvement (1)

2) Novel approaches. Continuous quality improvement. Echocardiograms in the offices of cardiology specialists.

A few novel initiatives have been developed in the different regions of the country to increase the efficacy of cardiology assistance. Some innovative experiments, known as “high resolution consultations” or “single act attendances”, aim at simplifying cardiology assistance and trying to perform the greatest number of necessary tests on the same day of the visit to reach the diagnosis, thereby eliminating unnecessary waiting times and hospital visits. These experiences have been organised both by hospitals and by individual services.

Quality improvement can be achieved through the use of an intuitive method or with the use of methodological tools like the Continuous Quality Improvement model (2). This method uses measurements of quality indicators to initiate and drive organisational changes in a never-ending cycle of continuous improvement. Implementing the model, however, requires organisational changes (3,4).

Medical assistance is no different from other “service providers”. This model involves a sequence of actions (alarm, fist visit, complementary test, results, diagnosis, information, treatment) with interactions between patients, physicians, specialists, nursing staff and other hospital staff. They act and interact, most of the time without written rules or protocols to provide service to the patients. When the process is inefficient, we must concentrate on modifying the process itself rather than the actors involved.

The continuous quality improvement model is based on analysing and defining the process, creating indicators and defining the “hot points” of the process, which give the process its value. The result is the development of “action plans” based on simplifying potential “hot points” and eliminating the rest of the process. The experience of “unique act attendances” is nothing more than an example of quality improvement in the cardiology office.

The simplest model of “single act attendances” is the availability of an echocardiogram in the office. Transthoracic echocardiography is the primary non-invasive imaging modality for the assessment of cardiac anatomy and function and is the most requested non-invasive test, requested by more than fifty percent of patients. Echocardiographic studies carried out after physical examinations “increase the value” of the information the cardiologists have.

The widespread availability of echocardiography makes the technique accessible to both in-hospital offices and offices independent of the hospital. The simplicity of training all new cardiologists in the technique and the evolution of the technology with secondary harmonic detection systems have also improved the quality of the images, simplifying and shortening the study times. Three or four minutes can be sufficient to exclude structural heart disease. The information obtained from echocardiograms provides not only clues to the diagnosis but also useful information that helps guide patient management.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology. 


1 Gibbons R J, Smith S C, Jr., Antman E. American College of Cardiology/American Heart Association clinical practice guidelines: Part II: evolutionary changes in a continuous quality improvement project. Circulation 2003;107:3101-3107.

2 Kritchevsky S B, Simmons B P. Continuous quality improvement. Concepts and applications for physician care. JAMA 1991;266:1817-1823.

3 Ovretveit J, Gustafson. Evaluation of quality improvement programes. Qual Saf Health Care 2002;11:270-275.

4 Smith R. Quality improvement reports: a new kind of article. They should allow authors to describe improvement projects so others can learn. BMJ 2000;321:1428


Vol5 N°28

Notes to editor

Dr Carlos Peña Gil
Santiago, Spain
Complexo Hospitalario Universitario de Santiago de Compostela

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.